Michiko Kitagawa, MD, Akiko Umezawa, MD, PhD, Kohei Uno, MD, Kotaro Wakamatsu, MD, Yosuke Seki, MD, PhD, Kazunori Kasama, MD, FACS, Yoshimochi Kurokawa, MD, PhD. Yotuya Medical Cube
Introduction: Inguinal hernia repair is one of the most frequently performed surgical procedures in general surgery. Especially, laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) has a tendency to increase in Japan. TAPP offers less postoperative pain and faster return to work and normal presurgery lifestyle. However this procedure is technically challenging especially to dissect the preperitoneal space at the ventral side. Tokumura et al. reported new technique about dissection of the preperitoneal space called tumescent TAPP. Herein we report two cases performing modified tumescent TAPP.
Methods and procedures: Under general anesthesia, the patient was placed on the supine position. A 12mm trocar was inserted umbilicus and two 5mm trocars were placed in the right side and the left side of the abdomen respectively. After identified hernia, we punctured the peritoneum for creating a preperitoneal space around hernia orifice using a needle catheter. 100ml of diluted ropivacaine and 100ml of CO2 gas were injected under the peritoneum. After injection, a peritoneal incision was made and the peritoneum was bluntly dissected from the preperitoneal fascia. Thereafter, we performed standard TAPP. After surgical procedure, ropivacaine peripheral nerve block was done by anesthesiologist for the management of postoperative pain.
Results: Both cases were right indirect hernia and the mean operating time was 138min and estimated blood loss was miniscule. They were discharged 1 day post-op and they had no postoperative groin pain. One patient had a small seroma of right inguinal region after 1 month operation.
The noteworthy point of is the amount of CO2 gas and the content of local anesthesia. Our main purpose of injecting an anesthetic and CO2gas is to dissect the peritoneum easily, that is, local anesthetic solution is used to lift up the peritoneum with edematous and CO2 gas is used to dissect it clearly. As soon as CO2 gas injected, the peritoneum can separate from preperitoneal fascia such as peeling off the paper and we can bluntly dissect it easily with less bleeding. For this reason, our technique has less of tumescent solution than original procedure and more than it about CO2 gas. Furthermore our technique offers less perioperative pain by injecting diluted ropivacaine solution and adding peripheral nerve block compared to original technique.
Conclusion: Modified tumescent TAPP is feasible technique. CO2 gas is effective to dissect the peritoneum and preperitoneal fascia and it makes it possible to perform this procedure more easily.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79410
Program Number: P038
Presentation Session: Poster (Non CME)
Presentation Type: Poster
